The effect of transdermal opioids on patient healthcare utilisation: comparison with oral opioids in the treatment of persistent (non-cancer) pain in North West Tasmania

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Henshaw, JS
(2013)
The effect of transdermal opioids on patient healthcare utilisation: comparison with oral opioids in the treatment of persistent (non-cancer) pain in North West Tasmania.
PhD thesis, University of Tasmania.

Abstract

‘These skin patch patients seem happier’.This chance remark from the pain clinic nurse, in 2007, was the seed that grew into this study. Increasingly, patients prescribed transdermal opioids, were being referred to the clinic. These medicines became available in North West Tasmania during the previous year. Until then, oral opioids were the mainstay of intractable chronic non-cancer pain (CNCP) treatment.The north west of Tasmania is a predominantly rural area of 22,492 square kilometres, with a population, in 2008, of 111,100 people. Access to healthcare is often more difficult here, than in with the major population centres, due to the ‘tyranny of distance’ and reduced specialist medical and allied health services available locally.This pain clinic, based at the NW Regional Hospital, opened its doors in 2005. The previous ad hoc system, provided by the anaesthetic department acute pain service, had become overwhelmed by the persistent pain workload. The catalyst for this was the well publicised withdrawal of VioxxTM (rofecoxib) in 2004, highlighting the potential long term cardiovascular adverse effects of both cyclo-oxygenase-2 selective inhibitors (coxibs) and standard non steroidal anti-inflammatory drugs (NSAIDs). Quickly, opioid analgesics were replacing coxibs and NSAIDs for the management of the painful musculoskeletal degenerative changes associated with aging, as their long term safety profile was predictable.Long-term opioid management is complex, in achieving a balance between efficacy of pain relief and minimisation of harm. Efficacy of pain relief requires stable therapeutic levels of medication, which may be difficult to achieve even with long acting oral opioid preparations. Minimisation of harm requires the reduction of untoward patient effects and the prevention of opioid diversion to the community. This requires significant healthcare resources to optimise patient care. Our newly arriving patients who were being treated with transdermal opioids seemed to be following a simpler path.If patients seemed happier with these transdermal medicines, they might need less frequent healthcare access. This concept framed the study. There was no published data available on the effect of the route of opioid analgesia, on healthcare utilisation, by persistent pain patients. This was the first Australian study to measure this in a rural context.This prospective longitudinal study compared 1804 months of healthcare activity by 198 subjects using oral or transdermal opioids. Subjects recorded details of all their ‘out of home’ healthcare contacts, together with the type, route, and dosage, of their opioid medication(s).There is a personal socioeconomic cost involved in accessing healthcare, and this increases in rural areas. Pain patients may use additional analgesics with their opioid analgesics. These related issues were assessed, as any benefit from reduced healthcare activity would likely be lost if patient costs, or their need for additional analgesics, increased.The study revealed that General Practitioner contacts were reduced significantly, by one fifth, and there was a trend towards less total healthcare activity, by patients using transdermal opioids. Pharmacy visits remained unaffected, probably as a consequence of the regularly repeated dispensing of all subject medications.Their personal socioeconomic costs involved remained unchanged. This included all out of pocket healthcare and travel expenses, together with the time taken to access this healthcare. On average, the subjects spent five hours each month and had out of pocket expenses of over one hundred dollars to do this.Additional analgesic and sedative use was unchanged, but there was a trend towards reduced use of short acting opioid analgesics for ‘breakthrough’ pain. Whether some patients have individual characteristics that enhance their response to the ‘steady state’ delivery of opioid medication by the transdermal route is currently unknown. If the risk of diversion is a consideration in prescribing opioid analgesics for rural pain patients then, at present, transdermal opioids are the safer option. If this leads to a reduction in the prevalence of opioid diversion in NW Tasmania, there are considerable economic benefits, both from a reduction in self-harm, and from drug enforcement costs.In NW Tasmania, transdermal opioids do seem to offer a benefit to patients compared to oral opioids. Reducing the frequency of General Practitioner visits is a good outcome in this rural area of limited health resources. Transdermal opioids are relatively simple and safe to use, both for prescribers and patients. As the population here ages, there will be an increased requirement for safe and effective pain relief for both degenerative and malignant pain. With the further development of these preparations, transdermal matrix opioids may open the door to the further relief of suffering and the living of fulfilled lives.This study has filled a gap in the knowledge of the effective management of opioid treated CNCP patients in rural Tasmania. This may be applicable to similar rural areas in Australia and elsewhere, where healthcare resources are limited.This thesis is presented as a series of published and submitted papers. Some repetition of text is unavoidable.